Provider Demographics
NPI:1770899577
Name:WIEDENMAN, KATYANA MARIE (MS)
Entity type:Individual
Prefix:
First Name:KATYANA
Middle Name:MARIE
Last Name:WIEDENMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KATYANA
Other - Middle Name:MARIE
Other - Last Name:ELESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1220 MAIN AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8201
Mailing Address - Country:US
Mailing Address - Phone:701-364-5433
Mailing Address - Fax:701-364-2256
Practice Address - Street 1:1220 MAIN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8201
Practice Address - Country:US
Practice Address - Phone:701-364-5433
Practice Address - Fax:701-364-2256
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1119235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist